Alessandra Dell’Era

Point-of-care coagulation monitors calibrated for the international normalized ratio for cirrhosis (INRliver) can help to implement the INRliver for the calculation of the MELD score

BACKGROUND/AIMS The MELD defines a score used to prioritize patients awaiting liver transplantation and includes results for bilirubin, creatinine and PT expressed as INR. It is assumed that the MELD for individual patients is the same regardless of the laboratory method used for testing, thus ensuring parity of organ allocation. Previous studies showed that the INR calibrated for patients on vitamin K antagonists (INR(vka)) does not normalize results across thromboplastins, whereas an alternative calibration called INR(liver) does. However, implementation of INR(liver) calibration for thromboplastins is difficult in practice. This study aimed to assess whether easy-to-run whole-blood coagulation monitors (widely used for patients on VKA) can be calibrated to measure efficiently the INR(liver) and minimize the interlaboratory variability. METHODS PT values for 61 cirrhotic patients were measured on native-blood with 2 monitors calibrated in terms of INR(vka). PTs for these subjects were also measured with a WHO-standard for thromboplastin. Paired-PTs with the monitors and the standard were subsequently used to calibrate the monitors in terms of INR(liver). INR(vka) and INR(liver) were then compared to assess for statistical significance. RESULTS The mean INR(vka) obtained with the monitors and the standard were significantly different (p<0.001). Conversely, the corresponding INR(liver) were not. CONCLUSIONS The INR(liver) calibration as previously described for thromboplastins works also for the easy-to-run whole-blood coagulation monitors. Once the monitors are calibrated by the manufacturer in terms of INR(liver) they could be used as near-patient-testing devices directly by the personnel of liver units making the determination of the INR for patients awaiting liver transplantation much easier and standardized.

Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation

BACKGROUND Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. METHODS Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2-3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. RESULTS Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12-440) vs. 43.4 days (13-489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31-321.6) vs. 43.4 days (13.0-489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. CONCLUSIONS Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence.

Invasive and Noninvasive Methods to Diagnose Portal Hypertension and Esophageal Varices

Assessing the presence of clinically significant portal hypertension and esophageal varices is clinically important in cirrhosis. The reference standard techniques to assess the presence of portal hypertension and varices are the measurement of the hepatic vein pressure gradient and esophagogastroduodenoscopy, respectively. Some newer methods have shown a good performance, but none has been proven precise enough to replace hepatic vein pressure gradient measurement or esophagogastroduodenoscopy for the diagnosis of portal hypertension or the presence and grade of esophageal varices.

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. A prospective study on safety, efficacy and long-term results

BACKGROUND Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages. AIMS To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients. METHODS All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation. RESULTS From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindos grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%. CONCLUSION A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Portal vein thrombosis in cirrhotic and non cirrhotic patients: from diagnosis to treatment

ABSTRACT Introduction: Portal vein thrombosis (PVT) may occur in non-cirrhotic and cirrhotic patients. It can be classified as acute (if a recent thrombus is present) and chronic (if portal cavernoma has developed). Patients can be symptomatic or may present signs and symptoms related to the development of portal hypertension. In rare cases bowel infarction may occur. Areas covered: This review provides an overview of the clinical presentation, complications, diagnostic challenges and available treatments for PVT in non-cirrhotic and cirrhotic patients (NCPVT). Expert opinion: Treatment of acute NCPVT aims at recanalizing the thrombosed veins and preventing intestinal infarction and portal hypertension. Anticoagulation should be started promptly and maintained for at least 6 months. Long-term anticoagulation should be implemented in the presence of underlying persistent thrombotic state. In chronic NCPVT, treatment aims at managing portal hypertension and portal cavernoma cholangiopathy and preventing new thrombotic events. In this setting, the indication for anticoagulation should be individualized. No formal recommendations can be given for PVT in cirrhosis, since there are no randomized controlled trials, prospective studies, or ad hoc guidelines. High quality studies, including randomized controlled trials, will be needed to provide robust evidence on the best treatment strategy.

Complications of Upper Digestive Endoscopy

Upper gastrointestinal endoscopy (UGIE) is extensively performed to diagnose and treat a wide range of disorders. Complications of diagnostic and therapeutic UGIE are preventable and should be recognised as soon as possible to institute the appropriate treatment. The commonest complications of diagnostic UGIE, besides those related to sedation, include aspiration, haemorrhage and perforation. Therapeutic UGIE including stricture dilatation, stent positioning, polypectomy and mucosal dissection may result in iatrogenic complications related to either the diagnostic or the operative procedure. The prompt recognition of adverse events, starting from the symptom and thanks to radiological assessment, allows optimising management of the patient and decreasing the iatrogenic morbidity.

Session 6: Consensus Statements – Vascular Diseases of the Liver in Cirrhotic and Noncirrhotic Portal Hypertension

Similar to the previous the Baveno conferences IV and V, a session in Baveno VI was dedicated to vascular liver diseases, focusing on the anticoagulation in non-cirrhotic portal hypertension and cirrhotic portal vein thrombosis.

Complications of Percutaneous Endoscopic Gastrostomy (PEG)

Percutaneous endoscopic gastrostomy (PEG) is a simple technique for the endoscopic placement of a permanent feeding access. The procedure is relatively safe and the technique well established. PEG can, however, be associated with serious complications and death. Following the rare PEG-related complication of an abdominal dislocation we review technique, indications and complications of this sixteen year old method.Percutaneous endoscopic gastrostomy (PEG) is a widely used method for providing nutritional support to patients with various contraindications to oral feeding. Complications of PEG placement can be due to the upper GI endoscopy performed and sedation but may also be specific to the procedure (haemorrhage, peritonitis, peristomal infection, necrotising fasciitis, tumour seeding, ileus, stomal leakage, buried bumper, gastric ulcer, fistulous tracts and inadvertent removal). This chapter reviews the main complications, their clinical manifestations and treatment options.

HVPG-Guided Prophylaxis

Portal hypertension is defined as an increase of the pressure in the portal vein system. Nowadays portal hypertension is generally assessed using HVPG measurement. 10 mmHg is the threshold for clinically significant portal hypertension when complications of portal hypertension (i.e., esophageal variceal bleeding, ascites) can arise. HVPG measurement, if performed properly, can give important prognostic information and guide the treatment of patients in primary and secondary prophylaxis and in case of acute variceal bleeding. Several studies have shown that the decrease of HVPG to ≤12 mmHg by chronic treatment, in primary and secondary prophylaxis completely prevents variceal bleeding. In case of a reduction ≥20 % from baseline, even though not below 12 mmHg, there is still a protection from variceal bleeding. About 30–40 % of patients in primary prophylaxis and 40–50 % in secondary prophylaxis achieve a reduction in HVPG to ≤12 mmHg or ≥20 % during chronic medical treatment for portal hypertension and can be considered good hemodynamic responders. Those patients who do not achieve an hemodynamic response are considered nonresponders and their risk of bleeding is about 30–40 % at 2–3 years in primary prophylaxis and 46–65 % in secondary prophylaxis. In the setting of acute variceal bleeding, the finding of HVPG values ≥20 mmHg was a predictor of high risk of treatment failure; these “high risk” patients may benefit from treatment with “early TIPS” placement.